Einarson et al. Annals of General Psychiatry 2012, 11:18http://www.annals-general-psychiatry.com/content/11/1/18

PRIMARY RESEARCH Open Access

Pharmacoeconomic analysis of paliperidonepalmitate for treating schizophrenia in GreeceThomas R Einarson1*, Maria Geitona2, Alexandros Chaidemenos3, Vasiliki Karpouza4, Theodoros Mougiakos5,Periklis Paterakis6, Dimitrios Ploumpidis7,8, Dionyssios Potamitis-Komis9, Roman Zilbershtein10, Colin Vicente10,Charles Piwko10, Panagiotis Kakkavas11, Konstantina Paparouni12, Rasmus C D Jensen13 and Michiel E H Hemels13

Abstract

Background: Patients having chronic schizophrenia with frequent relapses and hospitalizations represent a greatchallenge, both clinically and financially. Risperidone long-acting injection (RIS-LAI) has been the main LAI atypicalantipsychotic treatment in Greece. Paliperidone palmitate (PP-LAI) has recently been approved. It is dosed monthly,as opposed to biweekly for RIS-LAI, but such advantages have not yet been analysed in terms of economicevaluation.

Purpose: To compare costs and outcomes of PP-LAI versus RIS-LAI in Greece.

Methods: A cost-utility analysis was performed using a previously validated decision tree to model clinicalpathways and costs over 1 year for stable patients started on either medication. Rates were taken from theliterature. A local expert panel provided feedback on treatment patterns. All direct costs incurred by the nationalhealthcare system were obtained from the literature and standard price lists; all were inflated to 2011 costs. Patientoutcomes analyzed included average days with stable disease, numbers of hospitalizations, emergency room visits,and quality-adjusted life-years (QALYs).

Results: The total annual healthcare cost with PP-LAI was €3529; patients experienced 325 days in remission and0.840 QALY; 28% were hospitalized and 15% received emergency room treatment. With RIS-LAI, the cost was €3695,patients experienced 318.6 days in remission and 0.815 QALY; 33% were hospitalized and 17% received emergencyroom treatment. Thus, PP-LAI dominated RIS-LAI. Results were generally robust in sensitivity analyses with PP-LAIdominating in 74.6% of simulations. Results were sensitive to the price of PP-LAI.

Conclusions: PP-LAI appears to be a cost-effective option for treating chronic schizophrenia in Greece comparedwith RIS-LAI since it results in savings to the health care system along with better patient outcomes.

Keywords: Paliperidone palmitate, Risperidone, Long-acting injectables, Schizophrenia, Pharmacoeconomic analysis,Greece

IntroductionGlazer and Ereshefsky [1] were the first to conduct apharmacoeconomic analysis on patients affected withso-called “revolving door” schizophrenia. The label wasadopted to describe persons suffering from chronic dis-ease with multiple relapses, frequent hospitalizations,and problems with adherence to prescribed medications.These patients have many problems and obstacles

* Correspondence: t.einarson@rogers.com1Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5V3M8, CanadaFull list of author information is available at the end of the article

© 2012 Einarson et al.; licensee BioMed CentraCommons Attribution License (http://creativecreproduction in any medium, provided the or

preventing them from living a normal life. They are alsoresponsible for increased expenditures for healthcare, so-cial services, and the justice system [2].Antipsychotic drugs can help many revolving door

patients to remain in a stable condition; however, a majorproblem for them is adherence to these prescribed drugs[1,3]. The adherence of patients with schizophrenia isreduced over time. In fact, it has been demonstrated thatpartial adherence (i.e. missing 25-50% of doses) can reach50% in 1 year and 75% in 2 years [4]. An important ad-vance in enhancing adherence has been the depot form ofthese drugs, also referred to as long-acting injectables

l Ltd. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly cited.

Einarson et al. Annals of General Psychiatry 2012, 11:18 Page 2 of 8http://www.annals-general-psychiatry.com/content/11/1/18

(LAIs). They have become a mainstay in treatment be-cause of their prolonged effect and consequent preventionof much of the intentional and non-intentional non-adherence that results in treatment failures and hospitali-zations [3]. The clinically meaningful superiority of depotmedication compared to oral antipsychotic drugs in out-patients with schizophrenia has also been confirmed bythe findings of a recent meta-analysis which demonstratedthat depot formulations significantly reduced relapsesfrom an average of 33.2% to 21.5% [5].A further advance has been the development of atyp-

ical antipsychotics. They have advantages over the trad-itional drugs in that they improve both the positive andnegative symptoms of the disease [6]. A depot form ofatypical antipsychotic was not available until 2002, thefirst of which was risperidone (RIS-LAI) [7,8]. In a re-view of the clinical research, Möller concluded that RIS-LAI displayed clinical efficacy and a reasonable degreeof tolerability [8]. Moreover, based on the results of a re-cent multi-centre cohort study across 15 French regionsthat accounted for 77.6% of the French population in2005, RIS-LAI use compared to all other LAIs and firstor second generation per os antipsychotics was asso-ciated with a 34% reduced rate of hospitalization [9]. Aclinical disadvantage is that, although clinically effective,it must be administered every two weeks, usually by aspecially trained psychiatric nurse or physician [10].More recently, paliperidone palmitate (PP-LAI) has

been developed and approved by the European MedicinesAgency [11]. Among the other advantages that it shareswith existing drugs, this new product has an added advan-tage in that it may be administered monthly [12]. PP-LAIis already marketed in several European markets, mostoften at a higher acquisition price than RIS-LAI.Although the clinical use of PP-LAI has been investi-

gated in a number of randomized controlled trials [13-17],few economic evaluations have yet been conducted. Asearch of the international peer reviewed literaturerevealed one study from the USA that included PP-LAI[18]. However, that study did not use data inputs gener-ated by PP-LAI, but rather they used data from RIS-LAIstudies and assumed the two drugs to be exactly equal.Considering differences in dosing regimens, such assump-tions and associated cost outcomes may not be valid. Sev-eral pharmacoeconomic studies have compared RIS-LAIwith other drugs, mainly oral atypicals and traditionaldepots. In his review of those studies, Haycox found thatRIS-LAI was the dominant strategy in all eight differentcountries, using different analytical models [19].In Greece, a single pharmacoeconomic study by Gei-

tona and associates [20] was published which focused onpaliperidone extended release oral tablets. That studydemonstrated that paliperidone was cost-effective overall other oral drugs tested, including risperidone,

olanzapine, quetiapine, ziprasidone and aripiprazole.Paliperidone had the lowest overall cost and the highestnumber of days with stable disease. No other similarstudies from Greece could be located.Given that PP-LAI has a higher acquisition price than

RIS-LAI and taking into consideration the scarcity ofresources health care systems are faced with, economicevaluation of new technologies is important for decisionmaking purposes. The aim of this paper is to comparecosts and outcomes of PP-LAI versus RIS-LAI for thetreatment of persons with chronic schizophrenia inGreece.

MethodsPatient populationUnlike a clinical trial, patients are not recruited into thisresearch. Rather, a decision model was used to repre-sent the average patient being treated using standardapproaches.Therefore, it is necessary to define the population to

whom results would apply. The population of interestconsisted of patients having chronic schizophrenia withmultiple relapses, frequent hospitalizations, and pro-blems with adherence to prescribed medications. At ini-tiation of the analysis, all patients were stable andtreated as outpatients with maintenance doses of theirLAIs. For the purposes of this analysis, comorbiditieswere not considered even though they are common inthis population [21].

Drugs of interestThe primary drug of interest was PP-LAI, which wascompared against RIS-LAI. Long term use of PP-LAIhas been investigated in a number of randomized con-trolled trials [13-17]; one of these trials involved a com-parison with RIS-LAI [15]. As previously mentioned, theEuropean Medicines Agency has approved PP-LAI formonthly dosing [12], while RIS-LAI is administeredevery two weeks [10]. It should be noted that at the timeof this analysis PP-LAI was not marketed in Greece andthere was no local clinical experience.

Model and base caseData were modelled for one year using a previously vali-dated decision tree [22], which appears in Figure 1,adapted for use in Greece. An expert panel was recruitedand interviewed to provide clinical input describing pat-terns of patient management in this country. To enterthe model, an average patient with chronic relapsingschizophrenia must be an outpatient with stable diseasetreated with either PP-LAI or RIS-LAI. The patient canbe either adherent or non-adherent, according to pub-lished rates and expert opinion. Patients can remainstable or can relapse, with treatment either in the

Figure 1 Decision tree model used for the pharmacoeconomic analysis.

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emergency room or in hospital for severe cases. Thosewho cannot tolerate the primary drug or refuse to take itare switched to olanzapine oral tablets. In the event of asubsequent failure on that drug, clozapine oral tabletsare prescribed [23,24].

Table 1 Clinical inputs into the model and sources of informa

Rate RIS-LAI Source

Probabilities

Adherence 0.823 Olivares [26]

Adherent, stable disease 0.763 Calculation [1 - (ER exacerbationrate + hospitalization rate)]

Adherent, exacerbationrequiring ER visit

0.071 Ratio of ER vists: hospitalizationsAscher-Svanum [28]

Adherent, hospitalized 0.166 Olivares [29]

Non-adherent, stable 0.140 Kane [30]

Non-adherent,exacerbation

0.274 Calculation [1 - (Stable rate +hospitalization rate)]

Non-adherent,hospitalized

0.586 Assumption; PP rate adjusted based ocalculations by Mehnert & Diels [27]

Dosing

Maintenance dose 40.3 mgbiweekly

Fleischhacker [15], Kissling [32], Lee [3Lindenmayer [34], Olivares [29]

Dose after relapse 50 mgbiweekly*

Risperdal ConstaW Approved SummarProduct Characteristics [10] maximum

Dose afterdiscontinuation

50 mgbiweekly*

Risperdal ConstaW Approved SummarProduct Characteristics [10] maximum

Clozapine maintenanceafter failing both drugs

450 mgdaily

Simonsen[23], Wahlbeck [24]

Clozapine maximum dose 750 mgdaily

Simonsen[23], Wahlbeck [24]

ER emergency room, PP-LAI paliperidone palmitate long-acting injection (XeplionW)*A slightly higher average dose of 58.2 mg biweekly was used in clinical trials in paEerdekens[36]; however, they used a dose of 75 mg mg in some patients, which ismaximum.

Clinical inputsGiven the challenge of collecting valid local data forpopulating the model, which has also been identified inthe relevant literature [25], data on resource utilisation,frequency and duration of relapses were mainly

tion

PP-LAI Source

0.872 RIS rate adjusted via Mehnert [27]

0.803 Calculation [1 - (ER exacerbationrate + hospitalization rate)]

0.059 Ratio of ER vists: hospitalizationsAscher-Svanum [28]

0.138 Gopal [14], Hough [13]

0.148 Hough [13]

0.299 Calculation [1 - (Stablerate + hospitalization rate)]

n 0.553 Morken [31]

3], 69.3 mg monthly Gopal[14], Fleischhacker [15]

y ofdose

84.9 mg monthly Gopal [35], Pandina [36], Hough [16],Nasrallah [37], Pandina [38]

y ofdose

150 mg week 1,100 mg week 2, then84.9 mg every 4 weeks

XeplionW Product monograph [12],Hough [13]

; RIS-LAI risperidone microspheres long-acting injection (Risperdal ConstaW)tients with acute eacerbations of schizophrenia by Kane [5], Chue [35], andnot commercially available and which exceeds the now-recommended

Table 2 Cost inputs into the economic model (2011€)

Resource Item Unit Cost Source

Drugs paliperidone palmitate mg € 2.90 calculation*

risperidone microspheres mg € 2.52 calculation†

olanzapine tablets mg € 0.27 calculation†

clozapine tablets mg € 0.0023 calculation†

Medical visit/injection 1 visit € 10.12 Geitona [20], Urdahl [42]

Hospital emergency room 1 visit € 50.00 Syriopoulou [43]

hospital bed acute care 21 days € 146 for the first 21 days DRG tariffs{

hospital bed acute care 1 day € 45.00/day after 21 days DRG tariffs{

day hospital 1 day € 36.86 Geitona [20], Urdahl [42]*Based on available EU prices in the 22 countries used for reference pricing in Greece at the end of September 2011.†Based on hospital prices published in Price Bulletin 4/8/2011 and IMS Greece market shares July 2011.{Calculation based on officially published Ministry of Health Diagnosis Related Group (DRG) tariffs, Government Gazette B 1702/1-8-2011.

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extracted from an expert panel consisting of hospitalpsychiatrists. Other clinical rates and associated datainputs were determined from the literature (Table 1)[10,12-16,23,24,26-40]. The doses of drugs actuallyadministered in long term trials of these drugs wereused, rather than the Daily Defined Doses (DDDs) aspublished by the World Health Organization. DDDs rep-resent the average dose for the drug when used in itsmost common indication, which does not represent ourtarget population [41]. In the present analysis, the re-search hypothesis is focused on frequently relapsingpatients, necessitating hospitalization and intensiveintervention. Therefore, DDDs may underestimate thedoses used in the real world when treating thesepatients, whereas doses from the clinical trials could beconsidered as better proxy for real world dosing.

Cost inputsCosts were considered from the perspective of the Na-tional Health Service of Greece. We included only directcosts of care while indirect costs, such as time lost fromwork, were excluded (Table 2) [20,42,43]. We did notapply discounting because the analysis had a time hori-zon of one year. Prices were taken from official bulletinsor from the literature, then inflated to 2011 Euros usingthe Consumer Price Index for Greece [44].

Analysis and outputsFor each drug, we calculated the average cost per patienttreated. Patient outcomes analyzed included average dayswith stable disease, numbers of hospitalizations, emer-gency room visits, and quality-adjusted life-years (QALYs).To derive utilities (i.e., the quality weights) for this qualityadjustment, preference based estimates were obtainedfrom the literature [45-49]. Each of the three primaryhealth states (i.e., stable disease, exacerbation requiringemergency room treatment, and hospitalization) wereweighted using the average of the reported utility scores.

QALYs were then estimated for each drug by multiplyingthe amount of time in each health state by the qualityvalue assigned to that health state. Therefore, a cost-utilityanalysis was conducted, which involves calculating the in-cremental treatment cost per QALY as the pharmacoeco-nomic outcome. In addition, a cost-effectiveness analysiswas performed in order to assess other important clinicaloutcomes, such as the number of stable and relapse daysas well as rates of hospitalisation and emergency roomvisits.Several sensitivity analyses were performed to deter-

mine if alterations in clinical or cost inputs would influ-ence outputs. One-way sensitivity analyses were done toidentify break-even points, that is, what the values wouldhave to be in order for PP-LAI to cost more than RIS-LAI. We conducted one-way sensitivity analyses on im-portant parameters such as rates of adherence,hospitalization, and emergency room visits as well asdrug acquisition costs. Finally, all variables were variedover plausible ranges in a probabilistic sensitivity ana-lysis (also called a Monte Carlo simulation) with 10,000iterations. That analysis reproduces results for a largegroup of patients and gives a projection of what averagecosts and outcomes would be.

ResultsCost analysisThe total direct cost to treat one patient over the yearwas calculated for each drug, as presented in Table 3.Included in those calculations were drugs, medical care(visits) and hospital care, based on the units presented inTable 2. The overall cost to treat patients with PP-LAIwas lower than with RIS-LAI by €166, despite having ahigher acquisition cost. In the case of PP-LAI, drugsaccounted for the largest proportion of the total costs(61%), while hospitalization comprised 30% and medicalcare the remaining 9%. Costs for RIS-LAI had a similar

Table 3 Cost-utility analysis results from comparing paliperidone and risperidone long acting injections for chronicschizophrenia in Greece

Drug Total cost per patient* Total QALYs per patient Incremental cost per patient Incremental QALYs per patient Economic conclusion

PP-LAI €3,529 0.840 -€166 0.025 dominant

RIS-LAI €3,695 0.815 dominated

LAI long acting injectable, PP paliperidone palmitate, RIS risperidone microspheres, QALY quality adjusted life years.*All costs are in 2011 Euros.

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pattern of distribution, with 56% due to drugs, 33% hos-pital care and 11% medical care.

Cost-utility analysisThe primary pharmacoeconomic analysis was cost-utility,which simultaneously compares costs and QALYs. Alongwith costs, Table 3 also lists the numbers of QALYs asso-ciated with the use of each drug. In the base case, patientstreated with PP-LAI have a higher QALY score, meaningthat they experience more time with a higher quality oflife. Because PP-LAI has a lower cost and a greater num-ber of QALYs, it is considered dominant over RIS-LAI.That means it is the preferred treatment and should beadopted, providing it is affordable.

Cost-effectiveness analysisTable 4 displays the other clinical outcomes of interest,which were numbers of stable and relapse days as wellas rates of hospitalization and emergency room visits.Patients receiving PP-LAI experienced more days withstable disease and fewer days in relapse. Fewer of themvisited the emergency room or were hospitalized. SincePP-LAI has a lower cost and all outcomes were superior,it dominated RIS-LAI in all of these scenarios. Theseobservations confirm that PP-LAI is the preferred strategyto RIS-LAI.

Sensitivity analysesTo test the robustness of the model and its results, anarray of different sensitivity analyses were conducted. Inone-way sensitivity analyses, the model was insensitiveto variations in rates of hospitalization or emergencyroom visits. That means results would not change andfavour RIS-LAI regardless of how many patients werehospitalized or treated in the emergency room. As well,for cost equality between drugs, the adherence rate forPP-LAI would have to decrease by 28.5% (while that of

Table 4 Cost-effectiveness analysis results

Drug Stable daysper patient

Days in relapseper patient

Average visemergency roo

PP-LAI 325.0 39.0 0.1

RIS-LAI 318.6 45.4 0.1

LAI long acting injectable, PP paliperidone palmitate, RIS risperidone microspheres,*Total and incremental costs per patient are onsidered as in Table 3.

RIS-LAI remained the same), which is not a reasonablescenario.In the Monte Carlo synthesis, 74.6% of the 10,000

simulations favoured PP-LAI. Figure 2 depicts the scat-terplot of costs versus QALYs. All points below the hori-zontal line labelled €0.0 represent lower costs for PP-LAI and points to the right of the vertical line representgreater quality of life for patients treated with PP-LAI,as opposed to RIS-LAI.

DiscussionThis pharmacoeconomic analysis aims to assess the clin-ical and economic value of PP-LAI as a new treatmentoption in schizophrenia and to support decision makingwith respect to efficient allocation of resources withinthe Greek health care setting. Decision analytic model-ling was used to estimate and compare the costs andeffects of PP-LAI and RIS-LAI in outpatients withchronic schizophrenia within a 1 year time horizon. Inthis analysis, PP-LAI was the dominant treatment optionas it was associated with improved outcomes and alower average total treatment cost per year.Overall, the cost of treatment was slightly lower for

the healthcare system when PP-LAI was used, despite ahigher acquisition cost. It appears that the price of thedrug is more than offset by savings accrued from lessfrequent drug administration and higher adherencerates, as used in our model.The only other pharmacoeconomic analysis of schizo-

phrenia in Greece was that of Geitona and colleagueswho investigated paliperidone extended release tablets[20]. Their calculated cost was just over €7,030 for bothpaliperidone and risperidone oral tablets, with drugscomprising €1,541 (21.9%) and €1,293 (18.4%) of thetotals, respectively. Our overall costs were lower, pos-sibly reflecting the different patient population, i.e.. theanalysis by Geitona and colleagues focused on patients

its to them per patient

Average number ofhospitalizations per patient

Economicconclusion*

5 0.28 dominant

7 0.33 dominated

QALY quality adjusted life years.

Figure 2 Cost-effectiveness plot of the Incremental Cost Utility Ratio (X-axis = difference in QALYs, Y-axis = difference in costs in 2011Euros.

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with acute exacerbation, or some of it might be attribu-ted to the improved efficacy (i.e., via higher adherencerates) and the reduced hospitalisation rates associatedwith LAI formulations [50]. In our analysis, drugsaccounted for 61% and 56% of the total costs, respect-ively, which reflect the higher acquisition costs of theLAIs. Nonetheless, the final results were somewhat simi-lar, with paliperidone dominating risperidone.

LimitationsWhile reviewing these results it is important to keep inmind the potential limitations of this analysis. An appar-ent limitation was the fact that local expert panel wasused for estimating specific input parameters to themodel, namely, those associated with resource utilizationin the Greek setting. Although this approach has beenfollowed before in other similar studies [19,20], it couldlead to potentially biased estimates. However, in the lightof the absence of real life resource utilization data theexpert panel could give a picture of the actual clinicalsetting. Furthermore, in our model we did not includethe costs for treating adverse events. One reason wasthat the drugs are closely related, with paliperidonebeing a metabolite of risperidone [12]. Therefore, onemight expect the efficacy and safety profiles to be quitesimilar. In fact, that assumption of equal side effect rateswas made in a recently published pharmacoeconomicanalysis in the USA that included both of these drugs

[18]. Geitona and associates [20] did include some ofthese events, but found that the associated cost was triv-ial and had no impact on the model. Similar results havebeen reported by Vera-Llonch and coworkers [51], whoestimated the monthly cost associated with side effectmanagement for risperidone and olanzapine. It shouldbe noted that our model captured the discontinuationand switching rates, which are also attributed to adverseevents.

Health policy implicationsEfficient resource allocation has become a priority forpolicy makers across Europe and in Greece in particular.That applies to healthcare as well and to the manage-ment of patients with chronic schizophrenia. Health eco-nomic studies could provide significant tools for welldocumented and rational decision making given thescarcity of resources and the increasing control onhealth care and pharmaceutical expenditure. Pharmacoe-conomic analyses, like the one presented, give quantita-tive estimates of the costs of care and identify thepreferred choices for drug treatment. In the case of PP-LAI, its adoption would actually lead to savings for thesystem, since the overall cost of care would decrease.Both clinicians and managers within the system need tobecome aware of these analyses and use them to the ad-vantage of both themselves and patients.

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ConclusionsIn Greece, PP-LAI should be preferred to RIS-LAI fortreating patients with chronic relapsing schizophrenia be-cause it has both clinical and economic advantages. Theanalysis showed that PP-LAI has a lower overall cost tothe health care system and greater clinical benefits interms of QALYs, days in remission, hospitalizations, andvisits to the emergency room for exacerbations of schizo-phrenia. If adopted, it should result in net savings to thesystem of €166 per patient treated per year, along withbetter quality patient care. These findings could be furthervalidated when PP-LAI becomes commercially available inGreece and clinical experience is accumulated. Future re-search efforts, could focus on conducting economic eva-luations based on “real-life” data with respect to clinicaloutcomes and resource utilization in the local setting, pro-viding this way deeper analysis of the cost-effectiveness ofPP-LAI.

AbbreviationsPP-LAI: Paliperidone palmitate long-acting injectable; QALY: Quality adjustedlife-year; RIS-LAI: Risperidone long-acting injectable.

Competing interestsThomas Einarson received funding from the sponsor for this research and forthe publication of this manuscript. He has also received travel funding topresent similar results for Norway at the Latin American ISPOR conference inMexico City, 2011 and at the European ISPOR Meeting in Madrid, Spain inNovember 2011. In the past, he has received direct or indirect funding forunrelated work from Amgen Canada, Ferring Canada, Epicept, Generex,Industry Oncology Working Group (Canada), Janssen-Ortho Canada andNovo Nordisk.Alexandros Chaidemenos, Vassiliki Karpouza, Theodoros Mougiakos, PeriklisPaterakis, Dimitrios Ploumpidis, Dionyssios Potamitis and Maria Geitonareceived honoraria from Janssen-Cilag Greece Pharmaceutical SACI for theirparticipation in the experts’ panel.Mr. Hemels, Mr. Jensen, and Ms. Paparouni are employees of Janssen.

Authors’ contributionsTRE was the overall coordinator. TRE, MEHH and RCDJ conceived the studyand participated in its design. CV, CP, RZ, KP and MG participated in studydesign and analysis. AC, DP, VK, TM, DP, PP and PK participated indevelopment of clinical aspects of the model and data collection. All authorswere involved in drafting and/or revising of the manuscript. All have readand approved the final manuscript.

AcknowledgementsSupported by Janssen Pharmaceutica NV, Beerse, Belgium. The authorswould like to thank the members of the experts‘‘ panel: AlexandrosChaidemenos, Vasiliki Karpouza, Theodoros Mougiakos, Periklis Paterakis,Dimitrios Ploumpidis, Dionyssios Potamitis, for providing advice on localtreatment patterns and resource utilization and for reviewing the draftmanuscript, and also Prof. Maria Geitona for participating in the experts’panel and for reviewing the manuscript.

Author details1Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5V3M8, Canada. 2Faculty of Social Policy, University of Peloponnese, Korinthos,Greece. 3Psychiatric Hospital of Athens, Athens, Greece. 4Psychiatric Hospitalof Thessaloniki, Thessaloniki, Greece. 5401 Military Hospital of Athens, Athens,Greece. 6Dromokaitio Psychiatric Hospital of Athens, Athens, Greece. 7Clinicaland Social Psychiatry, University of Athens, Athens, Greece. 8Mental HealthCentre of the Psychiatric Clinic of Athens University, Athens, Greece. 9PrivatePsychiatric Clinic “Lyrakou”, Athens, Greece. 10Pivina Consulting Inc,Mississauga, Canada. 11Medical Advisor Janssen-Cilag Pharmaceutical SACI,

Athens, Greece. 12Janssen-Cilag Pharmaceutical SACI, Athens, Greece.13Janssen Cilag, Birkerød, Denmark.

Received: 26 March 2012 Accepted: 15 May 2012Published: 2 July 2012

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doi:10.1186/1744-859X-11-18Cite this article as: Einarson et al.: Pharmacoeconomic analysis ofpaliperidone palmitate for treating schizophrenia in Greece. Annals ofGeneral Psychiatry 2012 11:18.

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